Refer a Patient to Share Their Karmanos Story

Refer a Patient to Share Their Karmanos Story

Have you referred a patient to Karmanos Cancer Institute and feel like their cancer journey could impact someone with the same diagnosis or treatment? Did you and the patient take an innovative approach for treatment options and feel others could benefit from hearing this approach? Refer them to share their story with Karmanos' marketing team. Please fill out the information below — you may receive a phone call or email from a member of the marketing team.

Together, we give patients their best chance at beating cancer!

Disclaimer: By submitting this form, you are agreeing to share your information and have permission from the patient to share their information with the marketing team at Karmanos Cancer Institute for marketing purposes.

 

*Indicates required information

Contact Information

Your full name with title *

Your professional email address *

Affiliated health system *

Patient full name *

Patient email address *

Patient phone number *

Which Karmanos location did you refer the patient? *

Bad Axe	Bay City
Clarkston	Detroit
Farmington Hills	Flint
Gaylord	Lansing
Lapeer	Maumee
Mt. Clemens	Mt. Pleasant
Oakland	Petoskey
Port Huron	Roseville

Which Karmanos physician did you refer the patient to?

Why did you refer the patient to Karmanos? Also share why you think their story is inspiring. *

By submitting this form, you acknowledge that you have spoken with the patient and have received permission to share their information with the marketing team at Karmanos. If you have not received permission, please reach out to the patient and fill out this form once they have agreed. Also, by submitting this form, you acknowledge that you have informed the patient they may receive a phone call or an email from the marketing team at Karmanos. If you have not informed the patient, please reach out to the patient and complete this form once they are aware of possibly receiving communication from the team. *

I have permission from the patient, and I have informed them of future communication.

I have permission from the patient, but I have not informed them of future communication.

I do not have permission from the patient.

As a referring physician, Karmanos may like to include your testimony on this patient’s case, as well. Is it OK that we contact you? *

Yes

No